Female genital mutilation/cutting (FGM/C) is an ancestral practice
with deep social and cultural roots, involving the partial or total
removal of external female genitalia, as well as other injuries to
female genital organs for non-medical reasons (1). The World Health
Organization has agreed upon an international categorization of FGM
divided into four types, depending on the extent of genital tissue
removed: type [IOTA] (clitoridectomy), type II (excision), type III
(infibulations) and type IV (other). All four are considered as a human
rights violation (2).

Approximately 30 countries in Africa, the Middle East and Asia
carry out this practice, which is usually included as part of initiation
rituals for becoming an adult woman and obtaining legitimacy as a new
member of the community (3,4). However, each community possesses its own
defining feature with regards to the practice and they are usually
associated with myths linked to sexuality, religion and hygiene (5).

From a medical perspective, research has shown that FGM/C can cause
pain, bleeding, infection, urination problems, fever and even death.
Moreover, several negative long-term consequences have been widely
described, such as increased risk for urinary tract infections,
bacterial vaginosis, deformities and adhesions around the amputated
area, scarring and genital pain. These physical impairments could also
bring about obstetric complications in adulthood (6).

From a clinical sexology perspective, FGM/C is associated with
female sexual function impairments as measured by the Female Sexual
Function Index (FSFI), one of the most used psychometric instruments in
clinical research (7,8). Reduced sexual sensitivity, sexual activity,
enjoyment of sex, frequency of orgasm and persistent psychosexual
dysfunction have also been documented in genital circumcised women (9).
Other common sexual dysfunctions found in circumcised women are
genito-pelvic pain/penetration disorder and female orgasmic disorder
(10).

Although many studies uphold the negative physical and sexual
impact of FGM/C, research focused on the correlates of psychopathology
and FGM/C is still in its nascent stages. A higher prevalence of
posttraumatic stress disorder and other psychiatric symptoms, such as
higher levels of somatization, anxiety, phobias, and affective disorders
in circumcised women in comparison with non-circumcised women has been
described (11). Other authors have also cited different profiles of
FGM/C women according to employed coping strategies, arguing that this
practice does not affect all women equally at a psychopathological level
(12).

In addition to the psychopathological consequences derived directly
from this practice, consideration should be given to the interference of
the migration process to Western countries in women's mental
health, taking into consideration the reason behind their decision to
leave their country of origin. The complexity of the acculturation
process and integration to the host society could generate significant
emotional distress (13). Relatedly, receiving countries have increased
their interest in women with FGM/C by reaching out to women who suffer
from this condition (14-16). Coordinated approaches between health
professionals are under development in order to deal with FGM/C and to
improve clinical outcomes (3,17,18).

Clitoral reconstruction has numerous surgical (addressing
functional complaints), sexual (reduction of sexual distress and
dysfunction), and sociocultural, gender and anthropologic implications
(mainly identity recovery) (19). It is also noteworthy that this
surgical technique has been reported to aid in reducing local pain,
restore clitoral pleasure and improve vulvar appearance (20).
Nevertheless, an improved understanding of how this surgery impacts
women's genital self-image and sexual function is needed (21).

Taking into account the country where the present study was
carried, in 2001, the Spanish federal government created a multi-level
prevention program to increase awareness of FGM/C, although health
professionals in the majority of cases are not cognizant to the presence
of FGM/C due to underreporting (22). Three different types of prevention
programs were developed. First, specific "long-term"
systematic prevention is developed especially for pediatricians. Second,
"opportunistic" prevention consists of the clinician using
visits as an opportunity to address complications derived from FGM/C to
discuss the issue, provide relevant information and advice and to
investigate the circumstances of the patients' daughters, if it is
the case. Finally, community prevention seeks to inform and alert the
community through talks with associations and workshops (23).With
regards to interventions, to date, the hospital receiving the greatest
number of patients in Spain seeking genital reconstruction surgery is
the one featured in the present study. Therefore, taking into account
the current situation both in Spain and in the Western world, empirical
studies assessing mental health after genital reconstruction are needed
to better understand the implications of genital reconstruction and to
propose effective multidisciplinary interventions, especially in the
field of education and women's health. To our knowledge, no
empirical studies have jointly explored psychopathology, sexual
satisfaction and genital image in women with FGM/C before and after
clitoral reconstructive surgery.

Thus, our primary aim was to assess sexual function and distress,
psychopathology and genital self-image in a 26-year-old type II FGM/C
woman prior to FGM/C reconstructive surgery and at a six-month
follow-up.

Our main goal with the present study was to examine the
multidisciplinary and international implications of FGM/C. Although our
work interweaves three main fields, medicine, psychology and clinical
sexology, we consider that our findings may be of interest to other
areas, such as those examining FGM/C from an educational or
anthropological perspective. Health care providers require greater
knowledge of how clitoral reconstruction surgery affects women with
FGM/C and how to best manage patients.

Case Report

The present study was carried out jointly at the Department of
Obstetrics, Gynecology, and Reproduction and at the Department of
Psychiatry, Psychology and Psychosomatics at a private University
Hospital. Though it is a private hospital, a separate private foundation
financed the economic costs of FGM/C reconstructive surgery.

A 26-year old woman from Ethiopia came to the Hospital seeking
clitoral reconstruction after having undergone Type II FGM/C, according
to the WHO classification (2), at the age of 6 in her native country.
Taking this classification into account, the patient presented excision,
characterized by the removal of the clitoris and the labia minora. She
had been living in Ethiopia from birth until the age of 19, when she
moved to Europe, where she is living now with her parents and studying.
In Ethiopia, prevalence studies have reported that 74% of women have
experienced type [IOTA] or type II FGM/C (24). She reported having an
adjustment disorder characterized by anxiety symptomatology when she
arrived in Europe but endorsed not having had any other psychiatric
disorders prior to her arrival.

Taking her sexual history into account, she hadn't obtained
sexual education from her family due to cultural reasons. She once
attempted genital self-stimulation two years prior to seeking help but
ceased this sexual behavior because of feelings of guilt. Moreover, she
was sexually assaulted at the age of 18 and she chose to terminate the
subsequent pregnancy via a legal abortion. The rape was her first
experience with sexual intercourse. A few years later, she started to
maintain sexual intercourse with her boyfriend, though she suffered from
pain and bleeding. She reported a complete absence of sexual pleasure
during intercourse, as well as reoccurring pain. She reported wanting to
receive FGM/C reconstructive surgery to be able to experience sexual
pleasure and to improve the appearance of her genitalia and,
consequently, reclaim her female identity. However, she reported that
she had not informed her relatives about seeking the FGM/C intervention
because she was afraid of being rejected. She said she understood that
there was a strong cultural contrast between her country of origin and
her country of residence, and that there was a high probability that her
family would not approve of this decision.

Study Design

During the first baseline phase, initial psychometric, clinical and
sociodemographic information was obtained at the Department of
Psychiatry, Psychology and Psychosomatics. During the first phase of the
initial session, the patient individually completed the questionnaires
required for this study. Then, she was assessed in a face-to-face
clinical interview by an expert clinical psychologist with experience in
the field of FGM/C. Finally, considering the characteristics of the
patient's sexuality, the clinician provided sexual psychoeducation
to attempt to deal with remaining myths and false beliefs regarding
sexuality. In this case, myths related to sexuality, affectivity and
reproduction were addressed, contemplating that her first sexual
experience had been traumatic. During the second stage, she received
FGM/C surgery at the Department of Obstetrics, Gynecology, and
Reproduction with out-patient care visits to follow her progress. During
last period of the study, the patient was assessed at a 6-month
follow-up visit at the Department of Psychiatry, Psychology and
Psychosomatics with the goal of identifying changes in sexual practice,
mental health and genital self-image. At this visit, the patient also
received guidelines to facilitate her sexual interactions with her
partner after the surgical intervention.

The FSFI is a 19-item self-report measure which assesses sexual
function in females. It is made up of 6 domains: desire, arousal,
lubrication, orgasm, satisfaction and pain. It has been shown to have
good psychometric properties and clinical utility (27). The Spanish
version was validated by Blumel et al. (28). Sexual dysfunction was
assessed by adding the scores from the different domains of the FSFI.

Female sexual distress scale-revised (29)

The FSDS-R is a 13-item questionnaire which assesses different
components of sexual distress in women over the last 4 weeks. Items on
the FSDS-R are scored using a five-point Likert-type scale (never (0),
rarely (1), occasionally (2), frequently (3), or always (4)) and higher
scores indicate higher levels of sexual distress The original version
has demonstrated adequate reliability ([alpha] = 0.87 to [alpha] = 0.93)
and high test-retest reliability (r = 0.74 to r = 0.86) (29).

Genital self-image

Female genital self image scale (30)

This is a reliable and valid measure to assess female genital
self-image. It consists of seven items related with women's
feelings and beliefs about their own genitals, and it uses a 4-point
response scale: strongly agree, agree, disagree and strongly disagree.
The scale was found to have adequate reliability ([alpha] = 0.88).
Moreover, the scores in the questionnaire were found to be positively
associated to sexual function (30).

Other sociodemographic, sexual and clinical variables

Sexuality and psychosocial variables (family and personal
psychiatric history and current psychopathological examination) were
measured using a semi-structured, face-to-face clinical interview and
through DSM-5 female sexual dysfunction criteria (31). The DSM-5
recognizes these disorders as female sexual dysfunctions: female sexual
interest or arousal disorder (mainly characterized by absent or reduced
interest in sexual activity, sexual or erotic thoughts or fantasies and
sexual excitement or pleasure during sexual activity or to any internal
or external sexual or erotic cues); female orgasmic disorder
(characterized by a marked delay in, infrequency or absence of orgasm
and/or reduced intensity of orgasmic sensations); and the genitopelvic
pain or penetration disorder (mainly difficulties in vaginal penetration
or vulvovaginal or pelvic pain during intercourse).

Fgm/C reconstructive surgery

FGM/C reconstruction consists of recovering the remaining clitoris
and placing it externally as close to the vagina as possible. Firstly,
the scar tissue is removed from the skin to expose the clitoris. When
the residual clitoris is recognized, the clitoris is dissected from
bulbocavernosus muscles to obtain lateral mobility and the suspensory
ligament is sectioned. The anchorage of the gland is performed with a
figure of 8 Vycril 1 sutures that encroach both muscles, the public
periosteum and the ventral base of the clitoris. The skin is closed with
interrupted 3/0 stitches. Patients are discharged one day after the
surgery and check-up visits are scheduled two weeks, a month and a half,
and three months after surgery. During the first month the patient is
taught to perform daily care of the wound. Sexual intercourse is allowed
three months after surgery and a final evaluation is made at six months.

Results

Clinical outcome

No complications appeared during surgery and it was performed using
standard techniques. The patient did not completely adhere to the
postoperative follow-up wound care, completing the procedures on less
days than what was recommended. The patient's inconsistent
post-surgery wound care could have partially affected the outcome by
slowing the process of genital recovery.

Psychometric measures

Psychopathology

Table 1 displays the patient's main psychopathological
characteristics before and after surgery. During the baseline phase,
before surgery, the patient obtained clinically significant scores in
obsession-compulsion, interpersonal sensitivity, depression, anxiety,
hostility and psychoticism symptom-dimensions from Symptom Check
List-90-R. Six months following the surgery, the patient reported no
psychopathology alterations in any of the nine Symptom Check List-90-R
primary symptom-dimensions.

Sexual function, sexual distress and genital self-image

Sexual distress, function and intimacy outcomes are reported in
Table 1. The patient showed a slight improvement in sexual function six
months after surgery. Although specific increases in each of the FSFI
domains were not found, a global improvement in sexual function was
described through the total FSFI score.

A full remission of sexual distress was observed through the FSDS-R
questionnaire at the six-month follow-up. Nevertheless, the patient
reported altered genital self-image after FGM/C surgery. Finally,
referring to DSM-5 female sexual dysfunctions criteria, the patient no
longer met criteria for female orgasmic disorder and female sexual
interest/arousal disorder at follow-up. No changes were reported in
genito-pelvic pain/penetration disorder.

Discussion

We aimed to assess sexual function, psychopathology and genital
self-image in a 26-year-old woman with Type II FGM/C prior to clitoral
surgery and at a six-month follow-up visit.

Our findings showed that the patient presented relevant
psychopathological impairments before the surgery (using the SCL-90-R),
which could be related to both the ritual itself and to her migration
experience to Europe that took place 7 years ago. The fact that she
showed anxious symptomatology when she arrived in the country of
destination, as well as the need to conceal the reconstruction operation
from her direct family due to fear of possible repercussions, leads us
to think that the psychopathology presented before the intervention
could be related to these factors of cultural adaptation. However, these
symptoms were clearly reduced after the reconstruction. This result
dovetails with previous studies, which have also reported
psychopathological symptomatology associated to FGM/[C.sup.11]. In this
vein, different authors consider that this cultural practice usually is
associated with high emotional distress that may lead to post-traumatic
stress disorder symptomatology, anxiety, depression, as well as feelings
of betrayal and humiliation directed towards family members (11,32,33).
In addition, a possible explanation for the reduction of the previously
endorsed psychopathology presented by the patient could be related to
decreased emotional distress stemming from indecision prior to the
operation, as well as to the satisfaction of having decided thinking of
herself as a woman and her sexual satisfaction despite not obtaining
approval from her direct family. However, a clear relationship between
FGM/C reconstruction and psychopathological changes has yet to be
established.

Consistent with prior data, no improvement in orgasm function is
described after surgery (21). Despite this, the patient stopped meeting
DSM-5 criteria for Female Orgasmic Disorder after surgery. The clitoris
is understood to be crucial for female orgasmic functioning (10) and
therefore, patients that undergo clitoral reconstruction might need to
receive counseling on sexuality to improve their knowledge about this
organ and how to stimulate it to gain more pleasure.

Finally, our findings seem to contradict the hypothesis supporting
that genital self-image improves after a genital surgery. A study of
Goodman et al. (34) found that after two years of the plastic surgery
the differences between patients and the general population in body
image and genital self-image were absent, and that sexual satisfaction
markedly improved.

The results of this study showed a worsening in clitoral self-image
after surgery. It might be hypothesized that the clinical complications
and vulvar inflammation after surgery had an impact in clitoral
appearance and pain. Reasons as to why the patient did not report
improvements in her genital self-image and pain could be explained from
a clinical perspective. First, in some cases, given the severity of the
mutilation, it is technically difficult to obtain a notable improvement
after clitorial surgery. In addition, the lack of total compliance with
the wound care recommendations by the patient could have interfered with
recovery, although surgeons do not consider it the main interference
factor in clinical recovery.

Moreover, the follow-up was at 6 months after surgery and other
studies have observed an improvement after a longer follow-up period
(21). Relatedly, genito-pelvic pain/penetration disorder remained after
FGM/C surgery and this could also be explained by the lack of a
long-term follow-up.

Limitations

While this case report has strengths, we should consider the
findings with certain caveats in mind. First, the case study design does
not allow for the generalization of the results. Secondly, not including
a control subject and not controlling for external variables that might
have influenced the results of this study are limitations that should be
highlighted. Lastly, this study measured the medium-term effectiveness
of FGM/C reconstructive surgery and future studies should determine if
these effects are enduring.

Implications for International Practice

Depending on the outcome of the intervention, different options
should be considered on a practical level when considering women with
FGM/C. Regarding the countries of origin of women with FGM/C, both
prevention and sex education policies are required to effectively
disseminate the health and psychological impact that this practice has
on these women. As for Western countries, greater insight into the
physical and psychopathological consequences of FGM/C could bring about
policies that facilitate the acculturation process of women with FGM/C
who immigrate. Changing the perspective that women have regarding FGM/C
is not a straightforward process and it involves providing a path
towards enabling them to undergo a redefinition of themselves as women
who are faithful to their culture of origin and, yet at the same time,
able to carry out necessary separations from their past (4). In
addition, our results could help develop new screening tools for both
the educational and health fields.

Conclusion

To conclude, our findings support that improvements in
psychopathology and sexuality occur after FGM/C reconstruction surgery.
A detailed understanding of the biopsychosocial consequences of FGM/C
practice will allow for improving prevention policy and treatment
efforts. New empirical studies are required to gain a better
understanding of reconstructive surgery procedures, and to establish
more effective health intervention programs (21) and to address the
cultural practices associated with health risks.

Patient Informed Consent

The patient was informed about the study and signed informed
consent was obtained from her. The Hospital Ethics Committee approved
the procedures of this study.

Conflicts of Interest

The authors declare no conflict of interest.

Acknowledgements

We thank Rebeca Saez and Marta Gallostra for their contribution by
managing each patient visit to the two Departments of our Hospital. We
also thank Trevor Steward for his contribution by reviewing the English
quality of this manuscript.

Funding Statement

Fundacion Dexeus Salud de la Mujer financed the FGM/C surgery in
this research.

Contribution of Authors

GMB, ITS and MJB designed the experiment based on previous results
and the clinical experience of PBS, GL and JMF. GMB and ITS conducted
the experiment, analyzed the data, and wrote a first draft of the
manuscript. GMB further modified the manuscript.

References

(1.) World Health Organization.. WHO guidelines on the management
of health complications from female genital mutilation (No.
9789241549646). World Health Organization. 2016